Globally, more than 726,000 people die by suicide every year (World Health Organization [WHO], 2024). In 2022, approximately 13.2 million people seriously considered suicide, 3.8 million made a suicide plan, and 1.6 million attempted suicide (Centers for Disease Control and Prevention [CDC], 2024). Thus, suicide remains an ongoing public health issue warranting further attention. Scholars and clinicians have attempted to address this issue by developing theories, treatment modalities, and tools for risk assessment and management. Despite these ongoing efforts, suicide continues to impact countless individuals and communities, suggesting that current mainstream methods of understanding, assessing, and managing this form of risk are insufficient. Furthermore, despite the essential nature of risk assessment, a systematic review of interprofessional guidelines around suicide found that there is no clinical gold standard for suicide risk assessment (Harmer et al., 2024).
This gap is particularly wide in serving individuals who hold minoritized identities, as they experience additional suicide risk factors that are not captured by mainstream theoretical models of suicide and related risk detection tools (Chu et al., 2010; Marraccini et al., 2021; Stack, 2021). As such, there remains a significant need for culturally-informed suicide risk assessment education and training. Board-certified psychologists have a unique opportunity to model a high level of excellence in suicide risk assessment by incorporating culturally sensitive risk measures into their clinical practice. Here we will discuss one such measure, its theoretical underpinnings, and its clinical utility, which will be demonstrated with a vignette of a hypothetical client and a walkthrough using the measure.
Cultural Assessment for Risk of Suicide
The Cultural Assessment for Risk of Suicide (CARS) is a 39-item self-report measure of cultural suicide risk factors and manifestations of suicidal ideation or behavior (Chu et al., 2013). Analysis of the CARS within a sample of 950 adults from the general population demonstrated robust psychometric properties, with good internal consistency and significant convergent validity with other risk measures. For clinicians seeking a more time-efficient measure, there is a 14-item screener, the Cultural Assessment of Risk for Suicide, Screener version (CARS-S), that has also been shown to have high reliability, high correlation with the original CARS, and high convergent validity with measures of suicide-related constructs (Chu et al., 2017).
The CARS draws from the Cultural Model of Suicide (Chu et al., 2010), which encompasses three principles. The first principle asserts that culture influences the expression of suicidal thoughts, intent, plans, and attempts. In other words, culture affects one’s decision to deny or disclose their thoughts, as well as one’s choice of suicide method. The second principle posits that culture is linked to specific stressors that may affect suicide risk (i.e., minority stress, social discord, and cultural sanctions). The third principle states that cultural meanings associated with stressors and suicide play a role in suicidal tendencies, one’s threshold for psychological pain, and subsequent suicidal acts.
In line with these principles, the CARS is comprised of eight subscales measuring the following factors: family conflict, social support, idioms of distress (suicidal actions), idioms of distress (emotional/somatic), sexual minority stress, acculturative stress, non-specific minority stress, and cultural sanctions (Chu et al., 2010). The CARS is the first measure to operationalize a model of suicide that accounts for cultural factors across multiple cultural identities. As such, this measure may assist clinicians in more comprehensive risk assessment practices, particularly with individuals who hold minoritized identities and experience related stressors.
Vignette and Illustration of CARS Application
Susan is a 23-year-old Japanese-American cisgender woman who was referred by her primary care physician for headaches with no underlying medical cause. Susan immigrated to the United States with her parents when she was six. Susan describes growing up as “ok” and reports that she spent her time studying while her parents worked as doctors. She spends significant time on her phone each evening, scrolling through accounts of popular Asian American influencers reviewing makeup, clothes, and dietary trends. Susan is thin, and her body mass index is at the low end of normal. Susan states that her headaches “are always there.” Susan also reports feeling tired, although she reportedly sleeps 14 hours per night on the weekends. Susan does not remember when her headaches began, though she thinks they may have started after she had an abortion in high school, which her parents are not aware of. Susan states that her family is Catholic, though she is more interested in Shinto, and believes that her ancestors “speak to me” through nature. She reports feeling that her headaches are punishment by one of these ancestors. Susan also shares that “sometimes I feel like just disappearing and ending it all.” Asked whether she has a plan, intent, or any previous suicide attempts, Susan remarks, “well, I guess I have thought about what a bunch of pills might do to me.” Susan expresses feeling distant from others and describes a feeling of “disgust” about having suicidal thoughts that, if ever revealed, would bring great “shame” to her and her family. She also reports feeling that “suicide is a possible option to escape from misery.”
Given Susan’s presentation and salient identities, the CARS-S may be utilized to briefly assess for cultural suicide risk factors. See below for Susan’s completed CARS-S. Susan reported suicidal thinking without any plan, intent, or previous attempts. She also reported considering the means by which she might decide to “end it.” She further expressed feeling distant from her family, primarily because of her suicidal thinking and concerns about shame and stigma. Given her family background and culture, Susan experiences culturally-bound concerns that her suicidal thoughts may bring shame to her family if they were shared. Accordingly, her screener resulted in a total score of 43, falling above the necessary cutoff for a positive screen (37.5), which triggers the need for a comprehensive suicide risk assessment, which may include the full CARS and additional risk assessment tools, as needed.
The full CARS provides additional insight into Susan’s experience. See below for an example of Susan’s completed CARS questionnaire and CARS scoring form. Susan’s self-report on the CARS includes significant family conflict paired with emotional and somatic idioms of distress. Susan additionally endorses a moderate level of suicidal action-related idioms of distress, social support concerns, and minority stress. Finally, she reports mild amounts of acculturative stress, sexual minority stress, and cultural sanction-related issues. Awareness of these factors is imperative to accurately assessing Susan’s suicide risk and engaging in culturally responsive safety planning.
Susan’s CARS-S
The following questionnaire serves as an example of how Susan might fill out the CARS Risk Screener based on the vignette:
Susan’s Full CARS Risk Questionnaire
The following questionnaire serves as an example of how Susan might fill out the CARS Risk Questionnaire based on the vignette:
Susan’s CARS Scores
The following score table provides example score calculations that align with how Susan filled out her questionnaire based on the vignette:
Recommendations for ABPP Specialty Boards
As leaders in their fields of expertise, board-certified psychologists are at the forefront of improving culturally sensitive suicide risk assessment. Specialty boards can play an instrumental role in improving systems of education and training to improve and broaden their members’ suicide risk assessment abilities. Boards may consider establishing/monitoring eligibility qualifications, in addition to developing and utilizing culturally-driven suicide risk vignettes within oral examinations to evaluate candidate competence. Boards may also create and disseminate vignettes through digital means and artificial intelligence to approximate real-world scenarios clinicians may face related to culturally-bound or culturally-driven risk. By incorporating culturally sensitive suicide risk assessment and management requirements into its standard operating procedures, ABPP has the potential to increase its members’ cultural competence in risk assessment and, in turn, better serve the risk-related needs of its diverse client populations.
Education and Professional Practice Recommendations
The recommendations below are offered to improve culturally-sensitive suicide risk assessment education and training, broken down by group:
- Doctoral Graduate Programs: Consider creating and implementing a required clinical emergencies course with culturally informed suicide risk assessment and management training. This essential training will set a strong educational foundation for all future licensed psychologists in comprehensive, culturally sensitive suicide risk assessment. For an example of such training, see Appendix A for a list of topics covered in a clinical emergencies course offered at Palo Alto University.
- Doctoral Clinical Training Sites: Consider providing opportunities for trainees to serve clients presenting with unique cultural risk and protective factors associated with suicidal ideation and behavior. In addition, provide requisite supervision to assist trainees in developing risk assessment skills, including competence with administering and interpreting risk measures such as the CARS. Finally, consider incorporating the CARS into intake interview procedures. These actions will build a strong training foundation for future licensed psychologists to integrate culturally sensitive risk assessment as they begin working in clinical settings.
- Licensed Psychologists: Consider participating in continuing education programs and self-study focusing on culturally sensitive risk assessment, and remain abreast of relevant literature to practice continued growth and learning in this realm. For example, the Suicide Prevention Resource Center (SPRC) provides educational resources on culturally competent suicide risk assessment approaches (SPRC, n.d.). Consider reviewing APA therapy videos related to culturally sensitive intake and therapeutic practices on APA’s PsycTherapy website (APA, 2025). In addition, consider consulting with experts in the CARS and culturally sensitive suicide risk assessment. Dr. Bruce Bongar, PhD, ABPP, is one of the creators of the CARS and is available by email at bbongar@paloaltou.edu for any consultation questions that may arise.
- ABPP Specialty Boards: Integrate culturally sensitive risk assessment education and training content into relevant specialty boards via standard operating procedures such as guidelines, as well as oral examination and qualification requirements for members.
References
American Psychological Association [APA] (2025). APA PsycTherapy. https://psyctherapy-apa-org.paloaltou.idm.oclc.org/
Centers for Disease Control and Prevention. (2024, October 29). Suicide Data and Statistics. https://www.cdc.gov/suicide/facts/data.html
Chu, J. P., Goldblum, P., Floyd, R., & Bongar, B. (2010). The cultural theory and model of suicide. Applied and Preventive Psychology, 14(1-4), 25-40. https://doi.org/10.1016/j.appsy.2011.11.001
Chu, J., Floyd, R., Diep, H., Pardo, S., Goldblum, P., & Bongar, B. (2013). A tool for the culturally competent assessment of suicide: the Cultural Assessment of Risk for Suicide (CARS) measure. Psychological Assessment, 25(2), 424–434. https://doi.org/10.1037/a0031264
Chu, J., Hoeflein, B., Goldblum, P., Espelage, D., Davis, J., & Bongar, B. (2017). A shortened screener version of the Cultural Assessment of Risk for Suicide. Archives of Suicide Research: Official Journal of the International Academy for Suicide Research, 22(4), 679–687. https://doi.org/10.1080/13811118.2017.1413469
Harmer, B., Lee, S., Duong, T. V. H., & Saadabadi, A. (2024). Suicidal ideation. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK565877/
Marraccini, M. E., Griffin, D., O’Neill, J. C., Martinez, R. R., Chin, A. J., Toole, E. N., … Naser, S. C. (2021). School risk and protective factors of suicide: A cultural model of suicide risk and protective factors in schools. School Psychology Review, 51(3), 266–289. https://doi.org/10.1080/2372966X.2020.1871305
Stack, S. (2021). Contributing factors to suicide: Political, social, cultural and economic. Preventive Medicine, 152(Part 1), Article e106498. https://doi.org/10.1016/j.ypmed.2021.106498
Suicide Prevention Resource Center [SPRC] (n.d.). Culturally competent approaches. https://sprc.org/keys-to-success/culturally-competent-approaches/
World Health Organization. (2024, August 29). Suicide. https://www.who.int/news-room/fact-sheets/detail/suicide
Appendix A: Weekly Course Topics, Clinical Emergencies Course
Below are the weekly course topics covered in a clinical emergencies course at Palo Alto University:
Week 1-2: Introduction and knowledge base (definition of suicidal behavior; historical study of suicide; epidemiology; sociocultural, psychodynamic, cognitive-behavioral, and biological perspectives in research; suicide risk factors)
Week 3: Legal standards of care
Week 4-5: Assessment of elevated risk
Week 6: Outpatient and inpatient strategies for managing and treating a suicidal patient
Week 7: The cultural model of suicide
Week 8: Risk management – prevention and postvention
Week 9: Suicide risk in LGBTQ+ populations
Week 10-11: Student case presentations on risk assessment, triage, safety planning, treatment, and risk management with a hypothetical client
Holly M. McGrath, BA
Correspondence: hmcgrath@paloaltou.edu
Colin Simsarian, MA, MS
Correspondence: csimsarian@paloaltou.edu
Brenda Hammond, MS
Correspondence: bhammond@paloaltou.edu
Bruce Bongar, PhD, ABPP
Board Certified in Couple and Family Psychology
Correspondence: bbongar@paloaltou.edu